Failure to Complete Timely Skin Assessments Resulting in Advanced Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly assess and monitor the skin integrity of a resident who was admitted without pressure ulcers and assessed as low risk for their development. Despite having a care plan in place that included interventions such as regular repositioning, use of pressure-relieving devices, nutritional support, and weekly skin assessments by a licensed nurse, there were significant lapses in the execution and documentation of these interventions. Specifically, weekly skin assessments were not completed for three consecutive weeks, and shower sheets did not document any wounds or open areas during this period. A new skin issue was first identified as moisture-associated skin damage (MASD) with scabbing, but no detailed assessment or measurements were performed at that time. Subsequently, a wound nurse practitioner assessed the area and classified it as an unstageable, facility-acquired pressure ulcer with 100% slough tissue, requiring sharp debridement. The resident's care plan was updated to reflect the presence of the pressure ulcer, and dietary notes indicated an increased need for nutrition to promote wound healing. However, the pressure ulcer risk assessment continued to rate the resident as low risk, with no noted limitations in mobility. Interviews with facility staff confirmed the missed weekly skin assessments and the failure to identify the wound until it had reached an advanced stage. The facility's own wound management policy required weekly wound and skin assessments, and national guidelines emphasized the importance of comprehensive and ongoing skin assessments to detect early signs of pressure damage. The lack of timely and thorough skin assessments directly contributed to the development and progression of the resident's pressure ulcer.